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Date : 23/09/2004
Source: Ministry of Health
Title: N Madlala-Routledge: Health in Rural Nodes Conference


CLOSING SESSION REMARKS OF CONFERENCE ON "HEALTH IN THE RURAL NODES" By The Deputy Minister Of Health, Mrs Nozizwe Madlala-Routledge, Durban, 23 September 2004

Conference delegates,
Ladies and Gentlemen

I am very pleased to be able to join you today for the last part of this vitally important conference. I believe that more than half of the delegates are people living and working in the 13 rural nodes. Although I would have liked to be here from the beginning, it was not possible. But, as the aim of the conference was to bring you together to share experiences and assess progress, I am happy to close the conference and am looking forward the report and recommendations of the conference.

The Integrated Sustainable Rural Development Programme (ISRDP) is one of the most important programmes of this Government. It is very good that you have been meeting to review the contribution of the health sector to the ISRDP over the past three years, and that it is people from the rural nodes who have been speaking for themselves.

I sincerely believe that if we get our systems right at the district and village level, there is hope that our vision of delivering quality health care to all our people will be realised. The legal and policy framework is in place and our most important task now is to assess if our systems are working.

I know that the conference program has provided ample opportunities for you to speak and to present posters about your own experiences and I am pleased to hear that most of you have reported significant progress in a number of areas.

Improved functional integration between provincial and local government staff, providing personal Primary Health Care services in the rural nodes, is one area where most nodes have reported good progress. Another area of major progress is that of a District Health Expenditure Review that has been conducted in every node and, even more importantly, capacity has been built to continue doing these reviews each year without massive external support.

Thirdly, I am told, the collection of data and the use of information from the District Health Information System appear to have improved, and there is more of a culture of using information for management.

Development is a process that takes time. Our rural areas have been systematically under-developed over many years. Government is determined to accelerate the pace of delivery and to correct the historical imbalances. When you meet like this to assess progress and to share best practice, you strengthen the transformation agenda that the democratic government set in motion a decade ago, in 1994.

The first and most important step in addressing problems is to convince the people you serve that change is possible. That is why I am so pleased to hear that so many of you have reported positive changes over the past three years.

Of course there will be times for most of you to get frustrated, isolated and maybe even disheartened. But if you know from your own experience that change is possible, and if you can communicate that to others, then you will be making a major contribution to development. The national and provincial managers are here and I hope they have given you the assurance that they will continue to support your efforts.

I want to congratulate the facilitators from HST and from the HISP Consortium for all the positive feedback you have had. You are South Africans who are committed to the same goals as government but you are outside the management structures. You also have access to a network of like-minded people. The fact that the people you have been supporting have spoken so well, have reported so many positive changes and would like you to stay longer, is a tribute to you. But it also suggests that this model of using a facilitator to support our managers is worth exploring further.

It appears that managers in the rural nodes and managers in the provincial head offices generally agree that facilitation by the people from HST & HISP has been very useful. We need to consider allocating some of our own provincial budgets and advertising tenders and awarding contracts for South African NGOs to do this type of work in other areas.

I want to thank the European Union for the funding it has provided for this Rural District Health System programme, of which we can all be proud. I hope that you will be able to support other similar programmes in the future, whilst we examine provincial budgets to see where we could possibly find government funding for such NGO facilitation.

There are many challenges we face in improving health services in the rural areas. The greatest is the challenge of recruiting and retaining staff. In order to do this efficiently, we first need to know what staff, and what mix of staff, we need. Next, we need a Human Resource Plan for each health district. These plans are a requirement in terms of the new National Health Act, and they are essential if we are to meet this challenge.

I am very pleased to hear that a simple tool for developing a district HR plan has already been developed, tested and presented at this conference. If each district can use this tool to develop its own HR plan, these district plans can easily be consolidated into a provincial plan for human resources for PHC.

Other challenges that we face include reaching an agreement on a robust definition of the concept "rural". Perhaps we need a definition that takes into account the different degrees of isolation and "rural" in different parts of our country. But whatever definition we come up with, it must be one that all sectors and all government departments can use.

If we can do that, we can target issues like "rural allowances" and "rural transport strategies" and "expanded programmes of public works" in a coherent and coordinated manner. This is essential for Integrated Development.

The spectrum and content of rural health care is different from that provided in large cities. To have one standard apply to both urban and rural areas might mean closing rural hospitals and practices and forcing rural citizens to travel to distant sites, which in itself might lead to poorer outcomes.

Developing rural health issues of health care quality and patient safety standards that are practical, useful and affordable is critical. We need to guarantee core services in rural areas with an adequate cadre of well-trained, stable providers, working in well-equipped health settings should be appropriately planned and managed. I believe this is possible. What we need is to re-orient our systems and budgets.

That is why I wish to commend you on your efforts to develop a coherent rural health strategy. I look forward to seeing a document for discussion at the MinMec after it has been discussed by the Heads of Health Departments.

The vision of the Department of Health is to create a caring and humane society in which all South Africans have access to affordable, good quality health care. As part of implementing this vision, the department has expanded facilities and services in the provision of free primary health care. This has increased the number of visits per person to our primary health care facilities. This has put immense pressure on our health personnel, the majority of whom work under extremely difficult conditions. I wish to acknowledge our appreciation for the amazing work.

But, at the leadership level we need to work out a clear strategy for dealing with the problems faced by health workers, especially in rural areas. We need to understand the problems related to the supply and distribution of health care personnel in rural areas. This requires that we develop a coherent, affordable and sustainable plan for recruiting and retaining health care professionals. In particular we must attend to the issue of the high turnover and migration of staff from our rural health facilities.

This migration of staff has become an urgent issue for the Department of Health. Health professionals migrate because they are looking for better working conditions, including better remuneration and recognition of people efforts. As a developing country with many pressing and sometimes competing needs, South Africa is not in a position to compete with the international markets and at the same time it cannot stop this process of migration by health professionals. The quality of our health training is internationally recognised and the demand for our health professionals will remain.

The Department of Health, together with other stakeholders in Higher Education, Technikons and Professional Organisations might have to review our training strategy, and consider an approach that allows for training huge volumes of health professionals for the internal and international markets, while ensuring that the developed countries that benefit from our highly trained health personnel compensate us accordingly for this training.

Similarly, at the local and regional levels, the urban centres that benefit from the health professionals they poach from rural areas must plough something back to the rural areas they are helping denude of skilled personnel. They must accept the responsibility for care in especially the under-served areas is a priority of our government. Therefore, they too have a role in mitigating the trend of urban migration, by adequately compensating the rural areas they are depriving.

The Eastern Cape usually reminds us at MinMec about this fact that many of the senior managers in government come originally from the countryside. They also remind us that the rural areas are always left to carry the added burden of caring for those who can no longer work, who return from the cities either too old or too ill to work, or unable to find work in the cities and towns.

I was reminded sharply of this when I visited Umtata recently and had discussions with the District Mayor of O. R. Tambo. She informed me about the discussions she must still conclude with the Executive Mayor of Cape Town and the District Mayor of Ugu. She says many of her problems result from people in her district who go to Cape Town and Port Shepstone in search of work, who return to Pondoland when they are ill, too old to work or are unemployed. She says she is trying to convince these colleagues that while cities and towns benefit from the cheap labour from the countryside, they must be willing to share the responsibility of care. If we are to succeed in restoring the dignity of all our people, then these cities and towns must come on board and share the load, which presently the rural councils are left to carry on their own.

As the Department of Health we should investigate whether the regulatory environment in South Africa is not blocking South African health professionals from coming back to work here. We must investigate how to simplify the registration process and requirements.

We must consider the negative impact of the CPD systems, which only recognise training undertaken in South Africa. We must ask ourselves if the current approach is not discouraging those South Africans living and working abroad from coming back to work here.

We must discuss and review public policy issues related to the organisation, financing and delivery of comprehensive and integrated health care services in rural areas. We must assess the state of rural hospitals and clinics in the different areas and attend to issues such as the inadequate provision of infrastructure, vehicles and equipment.

We must attend to the mentoring and coaching needs as well as issues of training and technology. The ISRDP and extended public works programme give us opportunities to think creatively and to develop plans and strategies for strengthening health care delivery systems. We must also attend to the crucial area of monitoring and evaluation of our interventions as government, as part of our efforts to accelerate delivery. I know that sometimes councils are driven by the need to see immediate and visible results. What we really need are well-coordinated plans with long-term sustainable results. People must be trained and appropriate instruments developed for monitoring and evaluation.

This must be incorporated into the plans even as they go through the MTEF process. I am aware also of the problem of unfunded plans. We must step up our training on budgeting and funding systems, so that managers are able to translate the plans into workable projects. National Treasury and some of our departments are very concerned about this. But we need properly co-ordinated and focused monitoring and evaluation interventions for all spheres of government. We cannot simply pay lip service to determining if we are getting value for money. Remember always that it not our money, but that of taxpayers, yours and mine.

As you begin your individual journeys home, I hope you have been revitalised and energised. I hope you go back feeling ready to tackle the challenges, knowing you are not alone. I want to wish you well as you travel home. Drive safely on our roads and take the lessons of this conference back to our people in the rural areas. Report backs are important, but implementation must continue today.

Hambani kahle.

Issued by: Ministry of Health
23 September 2004

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